The next AA?

The next AA? Welcome to Moderation Management, where abstinence from alcohol isn’t the answer

So this was a headline that was kindly bought to my attention in March by a kind person on Mumsnet. It’s an American piece featured in The Guardian.

Upstairs from one of my favorite Oakland dive bars, 10 people of varying ages and backgrounds are sitting in a circle, talking about their drinking problem.

“I make plans for my non-drinking days so that I’m not thinking about it so much – I work out, I schedule late work meetings, so it’s not even a temptation,” a tall, thin older woman says. Later, she explains that there was a time not long ago when the idea of getting through any day without five or six drinks seemed impossible to her.

“Go out later, hold off on that first drink, set up a game for yourself like ‘I can only buy one drink and then I have to get any others I want bought for me’,” adds a young man in stubble and a newsboy cap. “Hold off on your second drink, too,” adds the older man sitting next to him. “I used to order my next drink halfway through my first, so I’d be halfway through my second before the effects of the first one would kick in and then forget about it.”

This is Moderation Management (MM), a program whose rising popularity and success rate is posing the first real challenge in decades to the traditional, black and white approach to addiction.

The program typically starts with 30 days off booze altogether – “doing a 30” in MM parlance – followed by a slow reintroduction of alcohol, and eventually a plan to limit your intake: no more than 14 drinks a week for men, nine a week for women, and no drinking more than three or four days a week for either. There’s increasing talk of applying MM to marijuana use as well, although that’s not officially condoned by the nonprofit of the same name, which administers the program.

“People do come in lately who want help moderating marijuana and because it’s still illegal in California, we shy away from it,” explains Marc Kern, the organization’s director. “That doesn’t mean they can’t come to meetings and listen and stuff like that. But in states that have legalized it, I can see a time where there’s a different MM – Marijuana Moderation.”

While there is a framework to MM, based on Kern’s book Responsible Drinking, it’s also a program that prides itself on flexibility and enabling people to find their own paths forward. Three out of the 10 people at the meeting I attended said they weren’t ready to do a 30 yet, but were planning shorter breaks. One man celebrated the fact that he’d taken one day off from smoking weed and drinking. He does both in moderation daily, and his concern was more about the frequency and the fact that he can never seem to take a day off than the amount of any particular substance consumed.

Another woman nearly started to cry when talking about issues with her son, her marriage, and her stressful job. She said the only thing getting her through was the bottle of wine she drinks every night. She’d had a few occasions recently where she blacked out from drinking, then spent days in bed depressed. The group gave her ideas for ways she could take a few days away from all of it – the stress, the husband and the drinking – and suggested more therapy to deal with the psychological triggers of her drinking and depression.

A young man in the group explained that he had bipolar disorder, that he was feeling great on his new medication, but that there might be a problem when it comes to alcohol. “I’m not someone who drinks when they’re depressed, I drink when I’m up,” he said. “If I’m feeling good, I want to be out being social, and that means drinking.” The group offered some tips and tricks for sticking to the four-drink-a-night maximum, and for finding ways to be social without drinking. When the older man sitting next to him talked about his daily marijuana use and how it keeps him from being too irritable about anything, the bipolar man raised an eyebrow and gently suggested that using marijuana as a mood stabilizer was different, and more problematic, than just smoking pot because you like it and think it’s fun.

There was no therapist in the room, and the moderator, a two-year MM “veteran”, gently steered people away from delving too deeply into issues that might be better addressed in therapy.

Moderation Management has been around since 1994, but it was living more or less in the shadows from 2000 to 2012, mired in controversy over its founder, Audrey Kishline. After starting MM, Kishline left the group, realizing that she could not moderate her drinking after all. She returned to AA, then fell off the wagon, drunk-driving in March 2000 and killing a man and his 12-year-old daughter. She was released from prison in 2003, and in 2014, plagued by guilt and other demons, Kishline killed herself.

In the year since since Kishline’s death, MM has had something of a resurgence, bolstered by the launch of the US National Institute of Health’s Rethinking Drinking program and a 2014 report from the Centers for Disease Control calling out “excessive drinking” as something both independent of alcohol dependence and a major public health issue that is not being addressed by currently available tools and programs.

MM began to add more in-person meetings and last year, the organization launched a campaign around Dryuary, encouraging people to take the month of January off from drinking. It was so successful, they now plan to do it every year.

“Historically, MM has been looked upon as enabling alcoholics, and then the tragedy with Audrey knocked us in the stomach and we really pulled back after that,” Kern says. “Only now, in the last year and a half to two years, have we started to come out again. The notion of figuring out if you can moderate, rather than going straight to abstinence as step one of dealing with an alcohol problem, is pretty universal. I haven’t talked to every single person in AA, but I’m sure they’ve all tried moderation on their own. But before MM there was no book or guidelines or anything, so people would just go out and try moderation naively on their own, and without any support a lot of them would fail.”

You can read the full article here. As you can imagine the comments were a riot!!

Here were two that resonated with me:

1. “The challenge surely is that problem drinking isn’t a quantitative thing; it’s more about why you drink rather than when, where and how much you drink; the old saw has it that having a glass with dinner is fine, not being able to have dinner without a glass isn’t. If that’s the case then moderation (as to amount) misses the point, because if the intention is still palliative, or celebratory or any one of the myriad reasons we’re told we (… ah, go-on) should let ourselves go a a little, then it’s the perception we need to moderate.”

2. “What the author may be alluding to is the application of harm reduction to alcohol.

Harm reduction is generally thought to be an effective approach to minimising the biological and social harms associated with illicit drug use.

Thus, both NGOs and researchers are drawn into the advocacy web woven by an industry sector understandably nervous of abstinence talk.”

And another commentor summed up my position nicely:

“The harm reduction model is a good place to start for a person who is in the ‘pre-contemplative stage’. This person is up against it, but not hard enough to see that the choice of whether or not to use has been completely lost, that the body is making the decision and bypassing what the person thinks of as his will or mind or whatever”

In my experience a phase of attempted moderation was part of the journey so any approach that encourages someone to look at their drinking is a good thing. It will be interesting to see how MM develops in this country …….

What are your thoughts?

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13 thoughts on “The next AA?”

I really didn’t like the description of making a game out of eking your 2 drinks out on a night out. Sounds like a rubbish way to live. Booze remains a focal point and just ‘too important’ by taking this approach I think. However, maybe for some people this approach is more palatable than considering giving up alcohol completely, and allows them to access structured support without having to be, or pretend to be, an alcoholic. For me, I am almost 2 years sober without AA or MM, I don’t think I am an alcoholic so AA was not for me, but I did want the simplicity of giving up completely rather than moderating so MM does not appeal either. Different strokes for different folks maybe. Being alcohol free is very liberating, I’m not sure that the MM route offers the same degree of liberation.

Hey CycleSal Firstly almost 2 years sober? Fantastic! Congratulations 🙂 It wouldn’t be my idea of fun either but as you say different strokes for different folks. You couldn’t pay me to drink now and I’m so happy that your life is so free and liberated minus it.

I kind of agree. One reason why I could not moderate (aside from the fact I always failed!) is that I grew exhausted with the constant thinking and bargaining and the central place alcohol took in my life and my thoughts.Abstinence is a great deal more restful!

What an utter tragic story about the founder though. Just dreadfully sad.

You know, one could just as easily say that Ms. Kishline’s story is evidence that AA doesn’t work. After all, she had left MM and gone back to AA prior to her drunk driving collision.

Even though the alcohol industry has latched onto the concept of harm reduction, that doesn’t mean that harm reduction itself is a bad idea. (To use an obnoxious analogy, that’s like saying vegetarianism is a bad idea because Hitler was a vegetarian. 🙂 )

We apply the principle of harm reduction all the time in our lives, generally with positive results. For example, choosing to wear a helmet when I mountain bike is an example of harm reduction. While I could avoid the risk of bike-related head injuries completely by NOT going mountain biking, I’m choosing to mitigate my risk instead. Likewise, a person who heeds expert advice to take at least 3 days off drinking every week is better off than a similarly situated person who does not follow that advice.

I think the mountain biker wearing a helmet is more risk mitigation than harm reduction. The mountain biker may fall and do damage to himself 5% of the times he rides by falling, while someone drinking alcohol is doing damage to himself 100% of the times he drinks, arguably even in small amounts. Risk mitigation is protecting against a small risk of harm, while harm reduction reduces harm that is measurably being done. I don’t think harm reduction is a bad idea, but for someone who has already been abstinent for a long time and is looking for a way to justify going back to a more “moderate” approach might be set up for failure. I think it might be a good way to approach things for people who know they drink too much and just want to do less harm to themselves, but long-term, I think anyone with enough of a problem to even consider a group to help moderate might not be likely to succeed long-term in moderating.

Hey sobergeek Thanks for reading and commenting on my blog 🙂 I agree with you about the question of whether it will work long term – I could never sustain moderate drinking hence why I stopped! Interesting analysis of risk mitigation vs harm reduction too – thank you.

My initial thought is that moderate drinkers moderate naturally. If one needs a program to be able to moderate, that’s a problem in and of itself. On the other hand, I could *not* for many years bear the thought of a life without alcohol, and so trying to moderate was very much a part of my journey. I didn’t seek out a program, it’s just something I tried (and failed at) all on my own. So maybe there’s a role for something like MM as it could well “catch” people earlier and prevent a lot of damage. I feel that if I’d have only gotten sober when I first started trying to moderate, I’d have prevented 90% of the fallout of my own alcoholism. It’s really ironic, how I did most of the damage in the last 10 years … after I became semi-aware that *maybe* I am drinking more than I should be. Then there’s the food example … there’s no denying that huge numbers of people need help to moderate their daily calorie intake – they aren’t doing it naturally and trying to do it naturally is making them fatter and fatter and fatter. So if there’s such a thing as “moderation management” for over-eaters, why not for problem drinkers? Personally, I love sobriety too much to go back now, but I’m not so arrogant to claim that there’s nothing to the idea.

That is a good piece. I think moderation management has its place and is certainly a way for a problem drinker to find out how bad the problems are. About 30% of people used to realise moderation was impossible and then went to total abstinance, while others who found it easier, stuck with the mm method.
Audrey Kishline used to follow my blog and I was really shocked when she died. The book face to face is amazing, and a true story of forgiveness and is very moving. It is a real shame she could not come to terms with what had happened, and that certain people tried to make an issue of her being from AA and moderation management depending on there own bias. There are many ways to recover, and the trick is find a method that works for you and motivates you. I have been abstinant for over 8 years now and that is the easiest way for me. Best of luck to everyone here.

Wow Lovinglife – Audrey Kishline followed your blog. So sad and tragic how things ended for her. I agree that it didn’t work for me but it was part of my journey and although I wouldn’t use it as a strategy going forward for others it may have a place. Be interesting to hear where you got those stats from as that it is a high if only 30% go on to abstinence and the others could moderate successfully.